Urology Flashcards
(143 cards)
1
Q
Which structures are lined by transitional epithelium (urothelium)?
A
- middle and lower thirds of ureter
- bladder
- prostatic urethra
2
Q
What are the functions of urothelium?
A
- stretch
2. relatively impermeable to urine
3
Q
What structure involved in micturition is under voluntary control?
A
external urethral sphincter
4
Q
What is urge incontinence associated with?
A
detrusor instability
5
Q
A pt with urinary dribbling incontinence secondary to BPH has what?
A
overflow incontinence
6
Q
A patient has a kidney stone 3mm in diameter on imaging. How should they be managed?
A
- analgesia
- oral fluids
stones smaller than 5mm usually pass
7
Q
How do you manage large (>5mm) troublesome renal stones?
A
- extracorporeal shockwave lithotripsy (ESWL)
OR - percutaneous nephrolithotomy
8
Q
How does schistosomiasis commonly present?
A
recurrent haematuria
9
Q
Why is BPH more likely to cause urinary obstruction than prostatic carcinoma?
A
because it affects the transitional zone of the prostate - these cells are the closest to the urethra
10
Q
What is balanitis?
A
- acute inflammation of the foreskin and glans
- associated with strep and staph
- more common in diabetics
- Rx with ABx and hygiene advice
- may require circumcision (particularly children)
11
Q
A 7y/o boy has excruciating sudden lower abdo pain and vomiting. He is pyrexial. ENT clear. What must you exclude?
A
testicular torsion
12
Q
What is the nerve supply to the testes?
A
T10 sympathetic pathway
13
Q
Why does testicular torsion in young children occur?
A
usually torsion of spermatic cord in a structurally abnormal testes
14
Q
How are testicular tumours often identified?
A
often incidentally following minor trauma to the scrotum
15
Q
What type of testicular tumour is common in patients >30y/o?
A
seminoma
16
Q
testicular swelling can be categorised into painful, hard and painles, and soft. Give examples of each.
A
painful:
- orchitis (viral/bacterial)
- epididymitis
- testicular torsion
- torsion of hydatid of Morgagni
hard and painless:
- tumour
- syphilus
- haematoma
- TB
soft:
- hydrocele
- varicocele
- epididymal cyst
17
Q
How do 95% of bladder cancers present?
A
painless haematuria
18
Q
What is the histological finding of most bladder cancers?
A
transitional cell carcinomas
19
Q
What are common PC of BPH?
A
- frequency
- urgency
- difficulty initiating urination
- post micturition dribbling
- incomplete sense of emptying
20
Q
List some risk factors for bladder cancer.
A
- working in rubber industry
- smoking
- schistosomiasis
- chronic bladder stones
- congenital abnormalities of the urinary tract
21
Q
What are the main functions of hydroxylated vitamin D?
A
- essential for bone mineralisation
- promotes absorption of calcium and phosphate from the gut
22
Q
What is a page kidney?
A
refers to the phenomenon of HTN that develops following long standing compression of renal parenchyma by subscapular renal collection
23
Q
Where are the ureters anatomically situated?
A
entirely retropertioneal
24
Q
What nerves are the ureters innervated by?
A
autonomic nervous system:
- sympathetic NS; T10-L1
- parasympathetic NS; S2-S4
25
The detrusor muscle is innervated by the autonomic nervous system; which branch makes you do what?
- Parasympathetic makes you Pee
| - Sympathetic makes you Stop peeing
26
Describe the muscle type, receptors and neurotransmitters of the internal and external urethral sphincters, respectively.
INTERNAL
- smooth muscle
- involuntary
- alpha 1 receptors
- noradrenaline
EXTERNAL
- skeletal muscle
- voluntary
- nicotinic receptors
- acetylcholine
27
Name the 4 parts of the male urethra.
1. prostatic urethra (transitional epithelium)
2. membranous urethra
3. bulbar urethra (stratified epithelium)
4. penile urethra
28
Which part of the urethra is the site where most idiopathic strictures in men occur?
the bulbar urethra
29
What are the 2 broad causes of urinary retention?
- obstruction
| - decreased detrusor power
30
What is the main cause of acute retention in males?
prostatic obstruction
31
List the possible causes of acute retention.
- prostatic obstruction
- urethral strictures
- anticholinergics
- 'holding'
- alcohol
- constipation
- post-op
- infection
- neurological e.g. cauda equina
32
What is the management of acute retention?
tricks to aid voiding
- analgesia
- privacy
- urinating to running tap
- urinating in hot bath
- ambulation
if fails:
- catheterize
- start alpha blocker - tamsulosin 400micrograms OD PO
- if in clot retention; need 3 way catheter
- 2-3 days later TWOC
33
What preventative medications can be given to avoid retention in BPH?
1. finasteride 5mg OD PO
- 5 alpha reductase inhibitor
- prevents conversion of testosterone to dihydrotestosterone (which drives hyperplasia in the prostate gland)
- decreases prostate size
- decreases retention risk
2. tamsulosin 400 micrograms OD PO
- alpha blocker
- decreases risk of recatheterisation after acute retention
34
How might pts in chronic retention present?
- overflow incontinence
- acute on chronic retention
- lower abdominal mass
- UTI
- renal failure
35
Which areas of the prostate to BPH and prostate carinoma affect respectively?
BPH - transitional zone
| Prostate carcinoma - peripheral layer expansion
36
What are the lower urinary tract symptoms commonly experienced with benign prostatic obstruction?
```
STORAGE SYMPTOMS
- hesitancy
- terminal dribbling
- weak stream
VOIDING SYMPTOMS
- frequency
- urgency
- micturition
```
37
How long do tamsulosin and finasteride take to have an affect?
tamsulosin - takes 1 week
| finasteride - takes 6 months
38
List some side effects of tamsulosin.
- drowsiness
- depression
- dizziness
- decreased BP
- dry mouth
- ejaculatory failure
- weight gain
39
What are the side effects of finasteride?
- low libido
- gynaecomastia
- impotence
40
What surgical interventions are used to manage treatment resistant BPH/BPO?
1. TURP
- transurethral resection of prostate
- 14% become impotent
2. TUIP
- transurethral incision of the prostate
- less destruction and less risk to sexual funcion than TURP
- but gives similar benefits
3. Retropubic prostatectomy
4. TULIP
- transurethral laser induced prostatectomy
41
What does BPH put you at risk of?
UTIs
42
How does the prostate feel in BPH?
enlarged and smooth to the touch
43
What is hydronephrosis?
swelling of the kidney due to build-up of urine
44
what is TUR syndrome?
absorption of bladder washout causing hyponatraemia and fits post TURP
45
What are the risks of a TURP?
- RETROGRADE EJACULATION
- haematuria/haemorrhage
- haematospermia
- hypothermia
- urethral trauma/stricture
- post TURP syndrome (hyponatraemia, hypothermia)
- infection - prostatitis
- erectile dysfunction
- incontinence
- clot retention near strictures
46
What is the mayo prognostic risk score (SSIGN) used for?
- predicts survival with renal cell carcinoma
- Stage
- SIze
- Grade
- Necrosis
47
what percent of renal cell carcinomas have metastasised by initial presentation?
25%
48
What investigation findings indicate renal cell carcinoma?
- FBC - polycythaemia from raised EPO secretion
- raised PTH --> hypercalcaemia
- raised ACTH --> cushing'like syndrome
- HTN from raised renin secretion
- LFTs - raised alk phos ?mets
- urinalysis; RBCs
49
Name 2 benign tumours of the kidneys.
1. renal fibroma/hamartoma
| 2. cortical adenoma
50
How are renal cell carcinomas treated?
- RCC in general is radio and chemo resistant
- 1st line: radical nephrectomy
- if unresectable/metastatic give biologic therapy e.g. sunitinib
51
What grading system is used for RCC?
TNM
T 1-4
N+/-
M+/-
52
What are common clinical features of transitional cell carcinomas?
- PAINLESS HAEMATURIA
- frequency
- urgency
- dysuria
- urinary tract obstruction
53
How do Wilms' tumours present?
- abdominal mass
| - haematuria
54
What is the commonest male malignancy?
prostate cancer
55
What are the risk factors for developing prostate cancer?
- positive family history
| - increased levels of testosterone
56
What type of caner is prostate most commonly?
adenocarcinoma
57
What would you find on examining prostate cancer (DRE)?
hard, irregular prostate
| 'craggy'
58
What investigations are done if ?prostate cancer?
- PSA
- transrectal USS + biopsy
- xrays
- bone scan
- CT/MRI
59
What are the treatment options for prostate cancer confined to the prostate?
1. radical prostatectomy
2. radical radiotherapy (+/- neoadjuvant & adjuvent hormonal therapy)
- external beam/brachytherapy
3. hormone therapy alone
- consider in elderly unfit pt
- delays tumour progression but refractory disease eventually develops
4. actice surveillance
- particularly if >70 and low risk
60
What are the treatment options for metastatic prostate disease?
- hormonal drugs may give benefit 1-2yrs
- 12 weekly goserelin (first stimulates then inhibits pituitary gonadotrophin)
- to counter act initial rise in testosterone give anti-androgen drug e.g. cyproterone acetate
61
What is phimosis?
- when the foreskin occludes the meatus
| - causes recurrent balanitis and ballooning in young boys
62
How does phimosis present in adulthood?
- painful intercourse
- infection
- ulceration
63
What is phimosis associated with?
balanitis xerotica obliterans
64
What is paraphimosis?
- occurs when a tight foreskin is retracted and becomes irreplaceable preventing venous return
- leads to oedema and even ischaemia of the glans
- Rx - 50% glucose-soaked swab, ice packs and lidocaine gel
65
What are common causative organisms of prostatitis?
- s. faecalis
| - e.coli
66
What can cause a rise in PSA levels?
- retention (therefore have to wait 6 weeks for accurate measurement)
- infection
- catheterisation
- surgery
- ejaculation
- BPH
- prostate cancer
67
How is prostate cancer graded?
gleason score
- used to describe histology of prostate cancer
- 1-5
- 1 - cells of relatively normal histology
- 5 - extremely dysmorphic cells
68
How is prostate cancer staged?
TNM system
69
Where are renal calculi formed?
collecting ducts
70
Where to renal calculi typically get deposited?
- pelviureteric junction
- pelvic brim
- vesicoureteric junction
71
How do you differentiate renal colic from peritonitis?
in renal colic the patient cannot lie still - opposite in peritonitis
72
What is the most common type of renal calculi?
calcium oxalate (75%)
73
What are the symptoms of pyelonephritis?
- rigors
- fever
- loin pain
- N&V
74
What is the classical pain description with renal colic?
- 'loin to groin pain'
| - may also get pain in genitals and inner thigh
75
Which conditions can a stone in the mid-ureter mimic?
- appendicitis
| - diverticulitis
76
What is strangury?
desire but inability to void
77
List the potential PC of renal calculi.
- renal colic
- UTI
- haematuria
- proteinuria
- sterile pyuria
- anuria
78
What is the favoured imaging for renal calculi?
spiral non-contrast CT
| but 80% stones are visible on KUB XR
79
What is the cause of cystine crystal formation?
renal tubular defect
80
What food types increase the risk of calculi formation?
- chocolate
- tea
- rhubarb
- strawberries
- nuts
- spinach
(they all increase oxalate levels)
81
What are the different causes of urinary tract obstruction?
```
LUMINAL
- stones
- blood clots
- sloughed papilla
- tumour
MURAL
- congenital/acquired strictures
- neuromuscular dysfunction
- schistosomiasis
EXTRA-MURAL
- abdo/pelvic mass/tumour
- retroperitoneal fibrosis
```
82
What is the imaging modality of choice with urinary tract obstructions?
USS
83
How do you manage upper tract obstructions?
nephrostomy or ureteric stent
84
How do you manage lower tract obstructions?
insert urethral or suprapubic catheter
85
What is periaortitis?
retroperitoneal fibrosis
86
What is the main type of bladder tumour?
>90% are transitional cell carcinomas in the UK
| adenocarcinomas and SCC are rare in the West
87
What type of bladder cancer does schistosomiasis give rise to?
squamous cell carcinoma
88
How are bladder cancers graded histologically?
- this is done for prognostic purposes
- grade 1 - differentiated
- grade 2 - intermediate
- grade 3 - poorly differentiated
89
What investigations would you perform on someone presenting with frank painless haematuria ?
- cystoscopy and biopsy (diagnostic of bladder cancer)
- urine; microscopy/cytology (?sterile pyuria)
- CT urogram is diagnostic of bladder cancer and provides staging
- MRI/lymphangopgram to look for nodal spread
90
How is bladder cancer staged?
```
TNM staging
Tis - carcinoma in situ
Ta - tumour confined to epithelium
T1 - tumour in lamina propria
T2 - superficial muscle involvement
T3 - deep tissue involvement
T4 - invasion beyond bladder
```
91
How are Tis, Ta and T1 tumours managed?
1. diathermy via transurethral cystoscopy
OR
2. transurethral resection of bladder tumour (TURBT)
- consider intravesical chemotherapeutic agents for multiple small tumours or high grade tumours
92
How are T2 and T3 bladder tumours managed?
radical cystectomy is the 'gold standard' (+ ileal conduit)
- post-op chemo toxic but effective
can do radiotherapy but worse survival rate
93
How are T4 bladder cancers managed?
usually palliative chemo/radiotherapy
94
How are bladder cancer patients followed up?
1. high risk tumours
- every 3 months for 2 years
- then every 6 months
2. low risk tumours
- first follow up cystoscopy after 9 months
- annual check ups
95
How does bladder cancer spread?
1. locally
- to pelvic structures
2. lymphatic
- iliac nodes
- para-aortic nodes
3. haematogenous
- liver and lungs
96
What is pyelonephritis?
infection of the renal cortex and medulla
97
What are the 2 main routes a kidney can become infected?
1. ascending route (from UTI) - not often at poles (inferiorly)
2. haematogenous route (e.g. IVDU, recent bacterial endocarditis) - at poles (superiorly)
98
What are the common causative organisms of pyelonephritis?
(same as lower UTI)
- E.coli
- klebsiella spp
- proteus spp
- enterococcus spp
99
List some risk factors for pyelonephritis.
- pregnancy
- vesicoureteric reflux
- stents/drainage procedures
- diabetes
- PBC
- immunocompromised
- neuropathic bladder
- enlarged prostate
100
What biological marker is used for identifying acute pyelonephritis in children?
procalcitonin
101
What is the first line investigation for acute pyelonephritis?
USS KUB
102
What is the most common cause of chronic pyelonephritis?
reflux nephropathy
103
What complication of pyelonephritis do you need to rule out and how will you do this?
- sepsis
| - blood cultures
104
What is the treatment for acute pyelonephritis?
current UK protocols for adults recommend ciprofloxacin/co-amoxiclav first line
105
What is pyonephrosis?
pus in the renal pelvis
106
What are the 4 main types of renal calculi?
- calcium oxalate
- calcium phosphate
- urate
- struvite
107
What % of renal calculi are visible on AXR?
50% of renal and ureteric stones are radio-opaque
108
How do renal calculi appear on CT KUB (preferred imaging modality for looking at calculi)?
radio-lucent
109
What are the 3 main types of incontinence in women?
1. functional incontinence
- pt caught short
- often due to immobility or unfamiliar surroundings
2. stress incontinence
- obesity and age RFs
- loss of small but frequent amounts of coughing in situations raising the intra-abdominal pressure (coughing/laughing)
3. urge incontinence/overactive bladder syndrome
- detrusor muscle contraction
- latchkey incontinence is a conditioned reflex
- do urodynamic studies
110
How is stress incontinence managed?
- 1st line - pelvic floor exercises
- ring pessary if prolapse
- surgery = tension free vaginal tape
- if surgery not suitable - duloxetine 40mg BD PO
111
How is overactive bladder managed?
- complete incontinence chart
- give topical oestrogen for vaginitis
- bladder training and weight loss are important
- medications: tolterodine 4mg BD (M3 antagonist) then try mirabegron 50mg OD (B3 agonist)
- if above ineffective consider intravesical botulinum toxin
112
What anticholinergics can be used to treat overactive bladder?
1. 1st line - tolterodine slow-release 4mg BD
| 2. alternatives are solifenacin 5mg OD and oxybutynin but these have more SEs
113
What must you rule out with an acute, tender enlargement of the testes?
testicular torsion
114
What must you rule out with any testicular lump?
testicular cancer
115
Which scrotal masses transilluminate?
- hydrocele
| - spermatocele
116
What are your differentials of scrotal mass if you cannot get above it?
- inguinoscrotal hernia
| - hydrocele extending proximally
117
What is your main differential for a separate and cystic scrotal mass?
- epididymal cyst
118
What is your main differential for a separate and solid scrotal mass?
- varicocele
| - epididymitis
119
What is a hydrocele?
- fluid within the tunica vaginalis
- primary/secondary
- primary can be due to patent processus vaginalis which resolves in first year of life
- secondary due to tumour/trauma/infection
120
How is a hydrocele managed?
- can resolve spontaneously
| - may require surgery or aspiration
121
What is the main cause of epididymo-orchitis in <35y/o?
chlamydia - treat with doxycycline 100mg BD
122
How does epididymo-orchitis present?
- sudden onset tender swelling
- fever/sweats
- dysuria
123
What is a varicocele?
- dilated veins of the pampiniform plexus
- left side more commonly affected
- distended scrotal blood vessels that feel like 'a bag of worms'
- PC ; dull ache
124
What is a varicocele associated with?
subfertility
125
What is a haematocele?
- blood in the tunica vaginalis
- occurs post trauma
- surgical incision and drainage might be needed
126
List the risk factors for testicular tumours.
- undescended testes
- infant hernia
- infertility
127
What are the tumour makers for testicular cancer?
- alpha-FP
- beta hCG
(help monitor treatment)
128
How is a seminoma managed?
exquisitely radiosensitive !
orchidectomy + radiotherapy cures 95%
129
How does testicular torsion commonly present?
- pain in 1 testis
- walking uncomfortable
- abdo pain
- N&V
130
What will the testis be like O/E?
- v tender
- hot
- swollen
131
What age group is testicular torsion most common in?
11-30 y/o
132
What is the main differential diagnosis of testicular torsion?
epididymo-orchitis (tends to be in older men though)
133
What is torsion of the hydatid of Morgagni?
- hydatid of Morgagni is a remnant of the Mullerian duct
- usually occurs between 7-12y/o
- less painful than testicular torsion
- thought to be due to surge in gonadotrophins which signal the onset of puberty
134
How is testicular torsion managed?
- need to gain consent for possible orchidectomy
- surgery to expose and untwist testis
- if salvageable return to scrotum and fix both testes to the scrotum
135
How many boys are born with at least one undescended testis?
3%
136
What is cryptorchidism ?
complete absence of the testicle from the scrotum
137
What is anarchism?
absence of both testes from the scrotum
138
What is a retractile testis?
- genitalia are normal but an excessive cremasteric reflex is present
- testicle often found at the external inguinal ring
139
What is a maldescended testis?
testis may be found anywhere along normal path of descent
140
What is an ectopic testis?
- testis in wrong location
| - usually in superior inguinal pouch
141
What are the complications of maldescended and ectopic testis?
- infertility
- increased risk of testicular cancer (risk remains after surgery)
- increased risk of torsion
- increased risk of trauma
- associated with hernias
- associated with other urinary tract abnormalities
142
What is an orchidopexy?
permanent fixation of testis + cord to scrotum
143
What medical treatment is there for undescended testes?
if testis in inguinal canal hormonal therapy with human chorionic gonadotrophin is sometimes attempted
